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Acute appendicitis is an extremely common cause for pediatric admissions, most notably presenting with right lower quadrant pain. There are few other etiologies for a young male to have pain aside from appendicitis. We present a young boy who presented with right lower quadrant abdominal pain and fevers, but was found to have funiculitis. Funiculitis, or inflammation of the spermatic cord, is a very rare condition in the pediatric population, almost always occurring in the elderly with urinary flow conditions. We share our case to remind providers the importance of a full differential diagnosis.

Background: Chylothorax occurs when chyle from the thoracic duct leaks into the pleural space. While majority of cases are iatrogenic, traumatic chylothorax can occur when rib or vertebral fractures disrupt the thoracic duct. These occurrences are exceedingly rare, particularly following blunt traumatic insult., Methods: We performed a retrospective review of a case of chylothorax following blunt trauma. Data was extracted from the electronic medical record., Case: A 60-year-old female presented to the trauma bay after a motor vehicle crash as a restrained driver with bilateral chest pain. Of note, patient had three left rib fractures from fall five days prior. She was neurologically and hemodynamically normal on arrival. Physical exam was notable for chest wall tenderness. Computed tomography revealed the following: bilateral hemopneumothoraces, pneumomediastinum, manubrium fracture, retrosternal hematoma, left 2-10 and right 1-2 rib fractures along with multiple orthopedic injuries. Left tube thoracostomy yielded 150 mL of blood. She was admitted to the intensive care unit. Patient had a 48-h period of cardiogenic shock requiring vasopressors and aggressive fluid resuscitation. On post-injury day (PID) 2, the chest tube drained milky fluid. Pleural fluid sampling was significant for triglyceride levels of 1292 mg/dL. Hemodynamics then improved. Due to low output (<500 mL/day), patient was managed conservatively a fat-restricted diet supplemented with medium-chain fatty acids. Chest tube was removed PID-7 once chyle leak resolved. Repeat chest radiograph PID-10 was negative for effusion. She was discharged to rehabilitation PID-13. At one-week follow-up, repeat CXR showed a small, loculated left lateral pleural effusion. Patient had no complaints and was maintaining adequate oxygen saturations on room air., Discussion: We present a case of delayed chylothorax after blunt trauma precipitated by increased central venous pressure secondary to right heart failure, aggressive fluid resuscitation and vasopressor use. Traumatic chylothorax should be considered in patients with pleural effusion in the setting of blunt chest trauma as sudden hyperextension of the spine can disrupt the thoracic duct. Delayed diagnosis is not uncommon due to an average latency period of 2-10 days. Pleural fluid with triglyceride level > 110 mg/dL and chylomicrons is diagnostic. Initial management consists of chyle reduction through diet modification (high protein/restricted fat diet). Octreotide can be used as a pharmacological adjunct. Refractory or high-output cases (>1000 mL/day) may require surgical ligation of the thoracic duct. Early identification and intervention are paramount as untreated chylothorax is associated with significant morbidity and mortality rates up to 50 %., Competing Interests: The authors have no relevant financial disclosures. No funding was received for this study., (© 2024 The Authors.)

Background: Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients., Methods: This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused., Results: A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%., Conclusion: Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock., Level of Evidence: Diagnostic test, level III., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Aim of the Study: The perfect balance between safety, cosmesis, and cost effectiveness in a world with ever growing healthcare costs has yet to be found for nonperforated appendicitis. The aim is to present our data regarding safety and cost effectiveness of the transumbilical extracorporeal laparoscopic-assisted appendectomy technique., Methods: A retrospective review was performed for all laparoscopic appendectomies for acute appendicitis from October 2014 to October 2016. All cases of perforated appendicitis were excluded (visible hole/abscess/free pus). Included cases were divided into two groups by operative technique: transumbilical (TU) or laparoscopic 3-port (L3P). Operating room charges were billed in 30-min intervals, and hospital charges billed per night in-house. The technique was that the appendix is identified with the laparoscope, grabbed with a grasper that is inserted parallel to the laparoscope, and exteriorized through the umbilicus. The appendectomy is completed extracorporeally., Results: A total of 494 cases of nonperforated appendicitis were included in the study. One surgeon attempted all cases with the TU technique (n=161), and all other surgeons used the L3P technique (n=333), which required an endostapler and a vascular sealing device. The TU technique was successful in 99 of the attempted cases. The mean operative time of the TU cases and the L3P cases was 21 (8-43) and 37 (12-73) min, respectively (P<0.001). The mean hospital stay for the TU and the L3P cases was 1.6 (1-5) days (one-night admission) and 2.4 (1-14) days (two-night admission), respectively (P<0.001). There were no operative complications or readmissions in either group. The overall cost of the L3P cases was 30% higher than the cost of the TU cases., Conclusion: The transumbilical extracorporeal laparoscopic-assisted technique was as safe as the laparoscopic 3-port technique. It offered all the advantages of a minimally invasive procedure, was associated with a significantly shorter hospital stay, and was remarkably more cost effective than the standard laparoscopic 3-port technique., Level of Evidence: III., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Only a few isolated cases in the literature exist to guide management of bilateral congenital lobar emphysema (CLE). Here, we review our experience in infants with bilateral CLE., Methods: A case series of all infants presenting with bilateral CLE from 2014 to 2015 in a single institution., Results: Four patients underwent intervention, with all having right middle lobe (RML) and left upper lobe (LUL) affected. Preoperative planning with computed tomography angiography (CTA) chest allowed a tailored approach based on specific radiologic features. All patients also underwent bronchoscopy to evaluate the anatomy and to assess for alternative causes of airway compression. Three patients underwent unilateral lobectomies, two RML and one LUL. All are growing normally and on room air more than one year later. The last patient underwent a staged procedure beginning with left upper lobectomy followed by right middle lobectomy two weeks later after exhibiting rebound hyperexpansion of the remaining diseased lobe. Thoracoscopy was precluded by mass effect in all patients. No patients underwent emergent lobectomies. One patient had pulmonary interstitial glycogenosis (PIG) in the setting of CLE, first reported case of bilateral CLE with PIG., Conclusions: This study supports a staged, image-guided, physiology-based operative approach to bilateral CLE. Excision of both diseased lobes does not appear to be mandatory, at least in the short-term follow up, and comports with a "the least intervention that is the most effective" philosophy. CTA is critical for planning, but the role of V/Q scan is not defined. Thoracoscopy appears to have no role., Level of Evidence: Treatment Study, Level IV., (Copyright © 2017 Elsevier Inc. All rights reserved.)